- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,243.54 / $1,243.54 / $2,086.13
| Professional | | $1,243.54 | $1,243.54 | $2,086.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,920.98 / $1,920.98 / $2,380.07
| Facility | | $1,920.98 | $1,920.98 | $2,380.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,243.54 / $1,243.54 / $1,243.54
| Professional | | $1,243.54 | $1,243.54 | $1,243.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,243.54 / $1,243.54 / $1,243.54
| Professional | | $1,243.54 | $1,243.54 | $1,243.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,158.20 / $1,219.16 / $1,292.31
| Professional | | $1,158.20 | $1,219.16 | $1,292.31 |